Provider Demographics
NPI:1710303573
Name:INNER PEACE THERAPEUTIC SERVICES, LLC
Entity Type:Organization
Organization Name:INNER PEACE THERAPEUTIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:GRANTLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:301-866-6333
Mailing Address - Street 1:PO BOX 1662
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20653-1662
Mailing Address - Country:US
Mailing Address - Phone:240-718-8460
Mailing Address - Fax:240-718-1906
Practice Address - Street 1:22776 THREE NOTCH RD STE 210
Practice Address - Street 2:
Practice Address - City:LEXINGTON PARK
Practice Address - State:MD
Practice Address - Zip Code:20653-3370
Practice Address - Country:US
Practice Address - Phone:301-866-6333
Practice Address - Fax:240-718-1906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC4189101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103219Medicaid